Provider Demographics
NPI:1255190252
Name:GURSHUMOVA, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GURSHUMOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 HANCOCK ST APT 1436
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-2482
Mailing Address - Country:US
Mailing Address - Phone:917-861-5554
Mailing Address - Fax:
Practice Address - Street 1:285 HANCOCK ST APT 1436
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-2482
Practice Address - Country:US
Practice Address - Phone:917-861-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI03065100122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist